Whiplash by liwenting

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                                       health.bcu.ac.uk/craigjackson
      Psychosocial
          Aspects
                of
         Whiplash
            Injury


                   Craig Jackson
Prof. of Occupational Psychology

          Division of Psychology
                            BCU
Whiplash

Harold Crowe in 1928, first used term to describe movement of
neck in accident

Acceleration then Deceleration

Now describes “injuries” induced by this motion

Arthur E Davis in Erie, Penn. first used term in 1945
“Most patients recovered well”

Used in 1953 in relation to auto-accidents (Gay & Abbott)
Used the term “psychoneurotic reaction” to explain delayed
recovery
RTA Figures
RTA Figures

Kills:        1,200,000 per year

Injured:     10,000,000 per year

RTA most common cause of Head Injury

Most Head Injuries are mild

Many left with long-lasting problems

Young males at biggest risk – alcohol often implied

Data suggests female drinking habits catching up with males
Implications for Female RTAs?
RTA Figures

80% of serious RTA injury is to head
1 concussion every 15 seconds in USA
Head Injury major cause of death and injury in RTAs
15,000,000 Brain Injuries per year in USA
       RTAs
       Playgrounds
       Sports


1990 - 5,563,000 intra-cranial injuries worldwide from RTA
                                                 Murray et.al 1996
Psychological de-briefing after RTAs may help
                                                Hobbs et.al 1996
RTA Figures
Mechanics of Occupant RTAs

Hazards:   Steering wheel / column

           Instrument panel

           Seatbelt

           Windscreens
RTA Brain injuries


Contre-Coup


Concussion


Intracranial Haematoma – Epidural, Intracerebral, Subdural


Diffuse axonal injury
How are Brain Injuries Assessed?

PAA
Post Accident Amnesia – memory problems when regaining
consciousness

• Minor Brain Injury
  Unconscious for < 15 mins

• Moderate Brain Injury
  Unconscious > 15 mins but < 6 hrs + PTA < 24 hrs

• Severe Brain Injury
  Unconscious > 6 hrs OR PTA > 24 hrs

• Very Severe Brain Injury
  Unconscious > 48 hrs OR PTA > 7 days
Mechanics of Whiplash




Hyperextension                     HyperFlexion


Majority of cases, no injury can be identified

Symptoms attributed to musculo-ligamental sprain
Mechanics of Whiplash

Accelerating   Duration        Acceleration   Head-Neck Movement
Phase

Phase 1        0-60 msec.      0g             Rest State

Phase 2        60-120 msec.    0.3 g          Head rise, neck flexion and
                                              backbone extension

Phase 3        120-200 msec.   4.3 g          Neck extension

Phase 4        200-300 msec.   2.8 g          Head and neck
                                              hyperextension

Phase 5        300-400 msec.   1.0 g          Head forwards with neck
                                              flexion (whiplash)

Phase 6        + de 400 msec. 0.8 g           Little flexion, back to
starting                                      position
Whiplash Associated Disorder

Transfer of energy into the neck

May result from rear-end or side
impact collision

Can occur with other accidents

Impact of injury can occur on soft tissue and bone in the neck

                           Can lead to a variety of clinical
                           presentations known as WAD

                              Whiplash injury feasible at 5 MPH

                         85% of UK RTA injury insurance claims
Whiplash Statistics

USA 1995:
5.5 million people involved in traffic accidents
53% of them suffered whiplash injury



Germany 1992:
395,462 traffic accidents
197,731 (49%) suffered whiplash injury
Whiplash as a “Pseudo Psychiatric” Condition?

American Psychological      Association   recognises   3   types
“dissimulating” disorders

1. Malingering
2. Somatoform disorders
3. Factitious disorders

Doctors, alternative practitioners, scientists,
lawyers, and patients have colluded in promoting
a disorder that now afflicts millions and costs
billions

While patients who sustain serious neck injuries
have a good prognosis minor collisions producing
no demonstrable tissue damage now result in
lifelong disability in around 10% of cases
Whiplash as a “Pseudo Psychiatric” Condition?

One of a family of fashionable conditions, including:
      Fibromyalgia
      Repetitive strain injury
      Chronic fatigue syndrome
      Occupational back pain
      Chronic pain syndrome

Are these diagnoses are offered to patients who are either
consciously or unconsciously seeking an escape from the
pressures of modern life into the roles of sickness and victim-
hood?

Do these conditions risk degrading medicine and bankrupting
health services? Worst of all, they condemn patients to
disorders from which there is little hope of recovery
                                                   Malleson 2002
Prevention is OK -

Lots of research in area of whiplash injury prevention



Cars better at preventing injury than ever before



Not much known about prevention of chronic pain after incident



Some treatment may foster chronic pain
Quebec Task Force on Whiplash

Extensive literature review of work from 1980 – 1993

10,382 papers examined

Only 62 (0.6%) were relevant and scientifically good

Papers before 1980 generally of little clinical / scientific value
Pathophysiology – a Sprain

Majority of whiplash injuries arise in soft tissue injury to neck
involving ligaments, joints, joint capsules, muscles and
tendons



Type 1:      Injury at microscopic level without altering
             structure

Type 2:      Partial tear at macroscopic level no separation

Type 3:      Severe stretching and tearing with separation of
             tissues
Whiplash Associated Disorders (WAD)

Classed by severity of signs and symptoms


WAD 0        No complaints or physical signs
WAD 1        Neck complaints but no physical signs
WAD 2        Neck complaints and musculoskeletal signs
WAD 3        Neck complaints and neurological signs
WAD 4        Neck complaints and fracture / dislocation


Most whiplash injury results from low impact collisions
Prolonged and Escalated Symptoms

Excess stress               10% have WAD symptoms for > 2
Psychosocial difficulties             years after accident:
Anxiety (approx 40%)
                                               Caused by. . .
Depression (approx 40%)
PTSD
Poor sleep                                        Poor sleep
Ear pain
                                 Depression, Anxiety, Stress
Poor posture
Dizziness                           Psychosocial difficulties
Memory problems                      Pre-existing conditions
Concentration problems
                                  Inappropriate therapeutics
Headaches
Movement difficulty                Prolongation of litigation
Post Traumatic Fibromyalgia?

Saskins & Moldofsky 1986
11 cases of PTFS
Generalised pain on 11 of 18 designated
tender points




A happy marriage of Whiplash and Fibromyalgia?

Post Traumatic Fibromyalgia abandoned in 1994
Wolfe 1996
Chronic Whiplash

Complex interaction between many factors:

                          Biological



        Psychosocial                           Legal



             Economics                  Beliefs / Attitudes


   Psychological factors are also hypothesized to influence
   the existence of whiplash-related cognitive impairments.
Other Countries 1

Mills & Horne 1986 – New Zealand
Very low incidence
Significantly lower than Australia
Difference in process of dealing with:   insurance companies
                                         lawyers
                                         therapists


Awerbuch 1992 - Australia
WAD claims dropped from 6000 to 2000 / year in 1987
Legislative changes limited compensation and claim sizes
Claimants had to: bear initial cost of claim
                    report to police
                    have minimum 30% disability
Other Countries 2

Cassidy et.al 1995 – Canada
27% reduction in claims under a “no fault system” in courts
Statute of limitations to 200 days after accident
“No Crash No Cash”


Obelieniene 1999 – Lithuania
No notion of chronic pain resulting from rear end collision
No fear of long term disability
No involvement of lawyers


Partheni et.al 1997 – Greece
91% of WAD victims recover in 4 weeks
Treatments – Quebec Task Force (1995)

Most studies show little or no efficacy of treatments

Collar and NSAIDs on short term basis

Avoid long term physiotherapy

Mobilization by trained person & active exercise for grade 2 & 3

Drugs for insomnia or anxiety

Early return to activities and promote mobility
Myths about Whiplash

1. “Whiplash Personality”

2. Malingering (for monetary gain) is common

3. Illness & Disability are biological phenomena

4. Men are more vulnerable than women

5. Direct impact upon neck is necessary for WAD

6. X-ray shows nothing so no WAD

7. Complaints are psychosomatic

8. Rest, time, muscle relaxants and tranquillisers cure the
   distress

9. Seatbelts would prevent injury
Case Summary of a Whiplash Patient

Male, Age 34.

Head Injury, Whiplash, Headaches, Sleep Disorder, Fatigue.
Suffered a head injury during an auto accident in which he was
rear-ended at 50mph. He described severe pain in his neck and
back and headaches that originated at the base of his skull and
spread to his left eye. His pain was so severe that it prevented
him from sleeping, so he suffered from severe fatigue. To
maintain some level of function during the day, he relied on
multiple caffeinated beverages such as jolt or bull colas and/or
coffee. At the time of his initial upper cervical chiropractic
evaluation (14 months after the accident), he had been suffering
with all of the above symptoms for over a year. He had sought
help from numerous practitioners including physicians,
neurologists, and therapists, to no avail. He reported receiving
some temporary relief from Pilates.
Case Summary of a Whiplash Patient

Female, Age 56.

Neck Pain, Headaches, Chronic Fatigue.
Suffered from chronic neck pain, headaches, and fatigue for
years. She thought the problems may have started sometime
after an auto accident she experienced 14 years before. During
the accident, she was hit head-on and totalled her car. The pain
bothered her on and off for years-- sometimes on a daily basis
and other times a month would go by without pain. She tried
many practitioners such as massage therapists and
chiropractors and received some relief but still the problem
continued year after year. Finally, after struggling over a
decade, she sought help from upper cervical chiropractic care.
Case Summary of a Whiplash Patient

Female. Age 52.

Migraine Headaches, Neck Pain, Whiplash, Head Injury.
Involved in two auto accidents three years apart. The first
accident (she was rear-ended) caused migraines, neck pain,
and head injury symptoms, including insomnia, depression,
memory loss, and inability to multi-task. These symptoms were
worsened after her second auto accident in which she was also
rear-ended. She tried multiple therapies including physical
therapy, chiropractic care, cranial sacral therapy, as well as
medications from her neurologist but she could hardly function
due to severity of her cognitive symptoms and pain.
Case Summary of a Whiplash Patient

Female, Age 49.
Headaches, Neck Pain, Loss of Sense of Taste
Involved in 6 different auto accidents during a 5-year period.
After each accident, she suffered increased pain in her neck
and head. Her third accident was most severe in that she
suffered a head injury. After that accident, in addition to
experiencing an increase in pain, she lost her sense of taste.
Her neurologist told her the damage to the nerves controlling
taste was most likely permanent and due to the head injury. She
tried many forms of treatment over the years including pain
pills, chiropractic care, and physical therapy. Sometimes she
received benefit, sometimes not, but the results were never
consistent or long lasting. After struggling for 8 years with
headaches and neck pain and 6 years with loss of her sense of
taste, she sought help from upper cervical chiropractic care.
Chronic Patient’s Attributions of Ill-Health

Work                  Environment                   Chemicals

Stress                Toxins                        Virus

Allergies             Anatomy / Ergonomic           Traumatic injury

                      Non-Traumatic injury


                    Living in a litigious society
                         “Victim” culture
                Living in a “risk-controlled” world
            Someone must therefore always be to blame
Urgency of Treatment?

Poor knowledge of management of acute whiplash symptoms

Best early treatment involves:
      1) Frequently repeated active sub-maximal movements
      2) Mechanical diagnosis
      3) Therapy


More effective in reducing pain than standard program of:
      a) Initial rest
      b) Use of a soft collar
      c) Gradual self-mobilization

This therapy could be performed as home exercises initiated
and supported by a physiotherapist
                                       Rosenfeld et.al 2000
Treatment For Patients – Cochrane Review 2004

15 studies met the inclusion criteria – only 3 were good quality
Overall a poor methodological quality

Passive & Active interventions more effective than no treatment

Found conflicting evidence about the effectiveness of active
interventions compared to passive ones

Data of the high quality studies were conflicting

„Rest makes rusty', can no longer be justified

There is a suggestion that active interventions are more
effective than passive ones, but no clear conclusion about
chronic WAD can be drawn.
Predictors of Disability in Patients

Reported frequencies of disability ranging from 0% to 50% in
follow-up studies

After 1 year, (7.8%) persons with whiplash injury had not
returned to usual level of activity or work

Initiation of lawsuit within first month after injury did not
influence recovery

The cervical range-of-motion test has a high sensitivity in
prediction of handicap after acute whiplash injury
                                                Kasch et.al 2001

WAD patients' self-efficacy at an early stage after injury
significantly predicts the development of pain intensity and
disability. Patients' confidence in performing daily activities
should be reinforced in order to optimize treatment after injury
                                              Kyhlback et.al 2002
Cognitive Dysfunction in Patients

Bosma & Kessells 2002

WAD Patients often experience cognitive impairments
Neuro(psycho)logical test results do not always support this

WAD Patients performed similarly to neurology patients on the
cognitive tasks and performed worse on memory and attention
tasks compared with the control group

WAD Patients had high scores on subscales measuring
somatization and displayed a palliative coping style

Somatization, in combination with inadequate coping, might
play a role in the development, persistence, or aggravation of
whiplash-related symptoms, such as pain or cognitive
dysfunction.
 Prognostic Factors in Patients

 Malt & Sundet 2002
 15% of WAD patients suffer long lasting health problems
 5% do not return to work

 Psychosocial impairment following injury is influenced by:

Vulnerability                                Symptom Formation
                      Biomechanical
Low mental ability                                   Musculature
Past mental illness   Neural structures    Acute stress response
Older age             Joints              Head position @ impact
Female                Musculature
Narrow spinal canal

Manual work, expectation of disability and an ongoing
compensation claim case seem to be important moderator
variables affecting symptom formation
Prognostic Factors in Patients

Psychological factors more important than crash parameters
(e.g. velocity) in predicting course of WAD at 6 months

Greater initial pain or symptoms persisting for 28 days were
associated with reduced QoL and PTSD symptoms
                                             Richter et.al 2004



Stress at time of accident predicted > symptoms at follow-up

Long-lasting distress and poor outcome were more related to
the occurrence of stressful life events than to clinical and para-
clinical findings
                                             Karlsborg et.al 1997
Prognostic Factors in Patients

WAD patients 2 times sensitive to cold in neck
Overall elevated level of distress > in the WAD gp than controls
Neither vibration or heat caused different responses

Pain in response to non-noxious stimulation over presumably
healthy tissues suggests that central mechanisms are
responsible for ongoing pain in at least some whiplash patients

                                                 Moog et.al 2002


WAD patients have lower pain thresholds for electrical stimulus
Hypersensitivity to peripheral stimulation in WAD patients

                                              Curatolo et.al 2001
Hassles and Daily Problems in Patients

“Everyday Problem Checklist” (EPCL) scores were higher in
WAD patients than healthy controls


Chronic WAD patients report a high stress load


WAD patients (especially those with a low educational level)
appear to be more vulnerable and react with more distress than
healthy people to all kinds of stressors


Stress responses probably play an important role in the
maintenance or deterioration of whiplash-associated complaints

                                           Blokhorst et.al 2002
Anxiety and Depression in Patients

Depression & Anxiety 2 years before accident, significantly
overlaps with WAD patients
                                         Wenzel et.al 2002


Depression & Anxiety greater in WAD patients than controls

Those with longest history of pain gave highest ratings of pain

Those with longest history of pain were most depressed

Most of these patients were involved in litigation.

Whiplash injury sufferers are anxious and depressed

Their psychological distress could be aggravated by litigation
                                                  Lee et.al 1993
Pre-injury Psychiatry in Patients

Outcome measured for 33 WAD patients and correlated with a
range of pre-accident variables

No association between pre-accident psychiatric factors and
overall outcome

Older age and pre-accident history of MSD complaints
correlated with physical and psychiatric outcomes

Pre-accident psychiatric factors may have little bearing on long-
term prognosis

Outcome of late whiplash syndrome is probably worse in older
individuals and in patients with a pre-accident history of MSD
complaints
                                               Turner et.al 2003
Expectation of Problems in Patients

Compared self-reported outcomes of physicians and non-
physicians

                             Physicians        Non-Physicians

Recall being in RTA?             71%                 60%

Recall acute symptoms?           31%                 46%

Symptoms lasting > 1 year?        9%                 32%

Physicians symptoms were shorter than non-physicians

Physicians appear, however, to be more resistant than non-
physicians to the progression from acute pain to chronic pain
and disability.
                                              Virani et.al 2001
Cognitive Model of Physical Symptoms in WAD
Preventing Chronicity of Pain

Teach professionals

Educate patients

Avoid anxiety provoking terms e.g. “PTFS” or “disc bulge”

Avoid excessive investigation & test – Iatrogenesis

Be rational

Avoid prolonged litigation involvement

Make patient aware of lengthy outcomes of litigation
Patient Education

Explain benign nature of WAD
Avoid confusing and conflicting info
Watch for factors leading to pain chronicity
Home / work programmes as effective as physiotherapy
Teach relaxation and stress management
Educate posture and neck care
Ergonomics at home and work
Home program of heat and cold & exercises
Self Monitor stress, sleep and mood
Headaches
Avoid excessive investigation
Acute Rational Care

Take good history

Physical examination

X-ray of cervical spine

Analgesics and muscle relaxants

Use of local cold and heat

Cervical collar for a few days

NSAIDS for few weeks

Gradual mobilization

Correction of disturbed sleep
Compensation Neurosis

Pending litigation

Treatment results often poor

Some overt malingering

Exaggerated illness due to:
suggestion          +       somatization
rationalization     +       distorted sense of justice
victim status       +       entitlement beliefs

Adverse legal / admin. systems

Harden patient‟s convictions

With time, care-eliciting behaviour may remain permanent
                                                  Bellamy, 1997
Compensation Neurosis

                      Improvement in health.....

                      ...may result in loss of status


Patient compelled to guard against getting better


Financial reward for illness is a powerful nocebo


Exacerbates illness


In a litigious society, will compensation neurosis become more
                             widespread?
Accident Neurosis

Failure to improve with treatment until compensation issue
settled

Accident must occur in circumstances with potential for
compensation payment

Inverse relationship to severity of injury - Accident neurosis rare
in cases of severe injury

Low socio-economic status favors accident neurosis

Complete   recovery common           following    settlement    of
compensation issue ? ? ?
                                                       Miller 1961
Abnormal Illness Behaviour after Compensable Injury
Accident neurosis                Accident victim syndrome
Aftermath neurosis               American disease
Attitudinal pathosis             Barristogenic illness
Compensatory hysteria            Compensationitis
Compensation neurosis            Fright neurosis
Functional overlay               Greek disease
Greenback neurosis               Invalid syndrome
Justice neurosis                 Perceptual augmenter
Post accident anxiety syndrome   Pensionitis
Postaccident fibromyalgia        Post-traumatic syndrome
Profit neurosis                  Psychogenic invalidism
Railway spine                    Secondary gain neurosis
Traumatic hysteria               Symptom magnification syndrome
Traumatic neurasthenia           Traumatic neurosis
Triggered neurosis               Unconscious malingering
Vertebral neurosis               Wharfie’s back
Whiplash neurosis                              Mendelson, 1984
Secondary Gain Pre-disposition

 Potential Claimants

• Military patients nearing severance

• Workers under retirement age

• Workers soon to be made redundant

•Low job satisfaction
                                        Non-economic motivation
• Members of support groups                            Loneliness
                                                      Depression
                                                          Anxiety
                              Difficulty expressing emotional pain
                    Previous history of attention seeking when ill
Summary of Whiplash

Most common injury following RTA (Spitzer et al. 1995)

Sufferers no more likely to be worriers or have psychiatric
problems than non-suffers who had RTAs

Sufferers more likely to find an accident frightening and be the
innocent party than non-suffers who had RTAs

33% of sufferers have psychiatric complications at 1 year after
accident

No “psychology of whiplash” – many physical and
psychological interactions combine together to produce a
complicated clinical problem
Finally. . .




It‟s a sexual thing – theory that anal retentive people (especially
    females) find being shunted / rear-ended to be distressing

 Is psychoanalytic theory any more unlikely than that of other
                    whiplash theories ? ? ?

								
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